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28098 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY N 1,DN(:-F.h;CI RICA. IgiRMI I No. CITY OFCUPERTINO APPLICATION/PERMIT rLunnnNG-MECHANICAL. 28098 BUILDING DIVISION BUII,UING 1'ROJF,CI'111FJVTIF'ICATION SANITARY N(I. AH'I.ICAIIUNSIIIIDIII'IAI,DAIIi BUILDING ADDRESS: loro'16 tate-M��Rv qP.1 LOI g OWNERS NA ,hppPUONE: CUNT RACI ORIS NAME, LIC NO: NA: I//pN'INOLp •IIIECEA: GINEER: ..IC NO: ADDRESS: � 1 J l� J MAMPS '++:• rt- BUILDING PERMIT INFO CONIACI: IaNB: QTY. .4.....�1 .,', . ELI; I'LlIMOPERMIT ISSLICENSED CONTRACTOR'S DECLARATION AP19.IANC1(ro OESCHII'I'ION ❑KZ Ihercbyi(Di-kml Pin lorvencdunder provisions nfChaPmr9(unnnancing with+TW7 Satin herchlofontht I lnfceBilnde prov'mrnsirma CrdeEurruniccnse with PANELSfull loaeanJcfft. U 0200200 ZW License Class Lie.g Comramr 201-1010 ASQ.EL 11.00H ARBA 5(SQ.FI. nNCHR1!CTS UECLARA)'ION OV,?n❑. ^ I an Z_0 I undersand my pinna shall be u.d as public record,. _ � 1 L zF'W SIGNS F:LEMICAL Y0..K'+ Licensed Pndexslsmal �e, OWN- UILDPR sCLARA'IION SPECIALCIRCUI'UMISC. ` CJa V 1 hereby affon Ihm m exernry from m.Cunn,ling L inns Low for the �,� y LLOv~i followingrcmnar Sect ?01L5,Busirrcasand orcnion,Cods:Any city or county ll!MP.MGfF.R(OR RA,F,)NST. e-� which rcgaircn a n to trmstmc,alcor,improv dcmnli,h,m Pe,dI any%want, J ROWER DEVICES rn} primmilaiasu ahorrymm"he.plirnntforaur rmitlofrleasignedstnemam <C) That he ice ' lord pureuort ter the Pnvsoon%of NC Cor arms%License Law(Chaper SWIMMING MOL 17LEMIC VALIIAI'ION _ 9(un n¢ncing with Scdinn Rggp of DirlildnJof NeB 'rte send hofc viola CrMq UE, mNa he is vemNrhrrefnnn end dM - afpt Ne allcBed cminion.Any violation of OGILISI$-SWI)CIIIiS-I'IX'I'IIRIiC "I�1 rrL—��.({�� CZQ Sectio ]0)LS by any applicant ra_ii - eapp'camp%ecicilpenellyuf int inn Than fve hundred d_ol (S NEW RESIDENT AI.ELECIR _SQ.FT. STORIES "FYPI:CONS'TRUCT'ION €� ❑ L vnflhP «awiNwagnav "anlecompcn,aion, willdnN work,endlh I, ndcdmoff rcdrhr ,(See 70,14.Business and Pride si ons C "or',Ijeeme Law ds not appy m an nwnerenr propenyw nbulld% iberson,andwhodoes hwnrkhimellmNmughhi% O<C.GROUT' RES.UNIIS n emplo ttP.,rm4dPJ 0 aM1impmvemenls mihmmkdmoffeed,f ilk.If. however th buildingora pr einem is sold tui nmeyearorcomplaion,SM1c owner huilAcr will nvelhehurde of provingdint JidnmbuilJmimpmveforpurpaseof _ . IcJ, .tr" y""' l �'(„FEE.,* ILOOU],ONE AVN Cl I.asowi r-efthepropeny.am ivelY contracting with llcehsed contractors w QTY. ,;,,,PLUMBING PERMIT,•"'e" ri '..7� ., ,0 comvucl the I jecl(Sec.]014. a sines%and profession,Code:)lloe ContousulPERMIT ISSUANCE Licencel.awd noteMlyuran net nfpropeny wholaildver impfovesrt thcon,and whomnnnnafnrchprnject iN a commctortJ licensed pursuant n the Contnemr'% ALITR-DRAIN&VENT-WATER(EA) FEE SUMMARY Berns.Law. O ISTD• ::5 ❑ 1 nm exempt a tt. B&P C fm this reason BACK II.OW PRRTECI'.Uf;VICEN SANITARY Y�_ RT:CEIrlP Dmc DRAINS-FLOOR,ROOF AREA.COND. SCIOULTAX Y N WORKMAN COMPENSATION DECLARATION RECEIPT IT I herehy coffin Nat l haven senifcmeofennsent to adf-whore,oracerlifcale of Il X'NRES-PER'I'RAP PARK FEE V N Worker;Compensation I....unicorn cetilird copy Nercof(Sec.3R00.lab C.)which RECI!Till'B enves.11 employee's at his permit. GAS-EA.SYS11IM-1INC.40 LISTS., BUII.DING DIVISION FES Policy a Cmnpmry GAS.EA.SVSIi!M.OVER 4(EAT PLANCIIE K11i1i Q ` ❑ CeniflcA rnpy is berehy famished ❑ Cetilied copy in fled with The city inspection division. GREASIANDUS I RI.W H OR GRADIN(;FRIT CERTIHCAIR OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE COMPENSATION INSURANCE (Un%section need not he completed iflhe pemtit is for one hundred dollars W00) SEWF- -SAN ORM En.2001-T. ENERGY PER or tear.) I certify that in the Performance of the work for which this permit is issued,I shall WA'H!R T WNF,NT/Ii1.liCTR nm employ any K—. in any manor P nes to berm aub*t la the wmkm• PAID Coon,rualionlawnof Celifco ice. [)all- 0 am WATI!R SYSl1iM/IRIinTING Dara R eiNa 2' Applicant Z, , MECHANI0 Mg SQ.I'I 'ItYfnl.: 0 NOIICC TfO AI'PL1GN'I^.IL,Tint making Nis Ccnifcam of lixemptian,You aM1nnlA Z � hcomesubjemmlheWorker'%Contpcnsatirnprovi.vionsoflheLNnCIMc,YOulsus BUILDING Hill � fmNwiN rnmply with inch prnvision.mlM1ia Rmrit shell be decmN rtvoked. Q 1 Q SIASMICFCI? YO CONS'IDUCT]ON IJiNDING AGENCY /aa Z Ihembyvflirmfor thereisamnsmunionlend;,,,.,ncyfor The peffnrmnnceof I IiLECTRIC V' 2V J O he work for which thin permit is issued ISer.:1f19].Civ.C.) _ _ ' Lendcr'%NamePLO G lL QTY. AL PERMIT FEB;„'IsndI ran,Addh I mnily Nnt I haveread Nin vpplicminn vnd anile Nm Ne shove infomnlion in MTiCIIAN AL I iliconed.I.gree to cmply with nll city and rnmmyo innncevvnA score Iowa rclmingm building wnarunion,vnJ berehy Pontotocreful rives of Ni%citym ruler upmvhe CON. IC`111 NTAX Z above-mamiorcd property fur;nap ma pnpnrses. AI;ILR UR AUU A)MECII. twat ngrtt m save,indemnify send keep ham as the City of Cupcnine against AIR HANDLING UNIT(TO Ip,lBp CPMO linhilities.judgmema,nnu ondeapena hlchmay anywayaccrue ngain3I, dCity OW AIR BANDIINO UI'I N (OVER 10.000 CPM) m cons,nen ingnfdi per ril. o Signature of ApplicamA:tmtra Uale EXHAUST 11(000 I WlDUCD PAID IIN,ARTR)US MAl1!RIALS UISCLOSTIRE IIEAUNGUNITOO W.00013'IU) Gum R cil Will the applicant or forme building recupam.sure or handle Im.noll ant"ind HEn'I'INGUNI'I'(OVI!R I)0.00001U) IYTA L: as def J by the Cupvnion Municipal Code,Chillier 9,12,and the)health and Safely Cade.Section 25512(,)? VENTILATION PAN(SINGLE RESIDE Cl Yea ❑No ISSUANC17 DAVE I101LI!R-COMP(?IIP OR 100,001 RTU) Will❑m apphcammfaint,ddcr,eg mrupemay AP Air Quality whidmmit .nodous air cunumminal as dcfncJ by Nc Bey Arca Air Vuvlity Managcmcnl BOILER-COMP(OVFR 100.000 DIU) I! 9 1 District? G 9-1 --95 Vn ❑NoNEWRESIDEN'TIALMECII. SQ.FTI have read the hnevrdona one ills requirenmoD under Chnpler 6.9.5 of rhe ifjusbonds, snormaPeoria. htitisyrelpeIuhdeastif@nt if Ne builJing Jae,nm m nts w have n st ls,thin it i%my rtnprce oility m irksa Na aruPem of the requirements which moat Fe mel Rim m inosine of a Cenifcnm of IIT hcupnnry. Uwnn m nnNnriacd xgcnt Dam I' IgSI11iD Dl' � a✓� OFFICE